Traumatic Injuries

Question 1

surgical procedures used to treat complex hand injuries - skin (3)

Answer 1

1. skin sutured in primary repair
2. graft/flap placed for wound coverage
3. skin left open for secondary closure

Question 2

surgical procedures used to treat complex hand injuries - tendons (2)

Answer 2

1. flexors/extensors repaired

2. tendon grafts, transfers, tendon removal performed in prep for future graft (often w/ temporary spacer)

Question 3

surgical procedures used to treat complex hand injuries - nerves

Answer 3

nerves repaired with or without grafting

Question 4

surgical procedures used to treat complex hand injuries - blood vessels

Answer 4

veins and arteries repaired with or without grafting

Question 5

surgical procedures used to treat complex hand injuries - bone (3)

Answer 5

1. bone fixation performed
2. joint arthroplasty implant inserted where joint surfaces cannot be repaired
3. joint fusion

Question 6

order of repair in traumatic hand injuries

Answer 6

1. bone fixation
2. tendon (unless vascular status severely compromised)
3. vascular and nerve repair
4. skin

Question 7

general info needed from physician/surgeon (4)

Answer 7

1. what to hold and what to move
2. what was injured, at what level, and what was repaired
3. what type of injury
4. what are expected outcomes/goals

Question 8

info needed from surgeon following surgical repairs (11)

Answer 8

1. structures repaired and how
2. quality of repairs
3. strength of repairs
4. any tension on repairs
5. tendon quality/repair site in relation to pulleys
6. strength of any fracture fixation; presence of fusions; joint mobility; bone shortening
7. any skin graft/flap precautions required
8. any tissues/ROM to be protected
9. any tissues with questionable viability that need to be watched
10. anticipated time frames for progression
11. any structures not repaired/plans for them

Question 9

types of bone fixations (7)

Answer 9

1. bone grafts
2. fixators
3. wires
4. pins
5. plates
6. screws
7. other devices

Question 10

bone injury precautions (2)

Answer 10

1. Avoid excess stress at the fracture or fusion site or pin site and watch for signs of infection.
2. A joint next to a fracture may need to be moved to begin ROM protocols. Be aware of the location and type of fracture and the fixation and stability. Manually stabilize the bone during movement, and do not torque across the fracture site.

Question 11

ROM and bone injuries

Answer 11

if the surgeon established sufficient fracture fixation, ROM around fracture site may be initiated immediately, starting from midrange and progressing to full ROM as appropriate

Question 12

revascularizations precautions (11)

Answer 12

1. keep hand warm and avoid exposure to cold or sudden/extreme temperature change
2. no eating/drinking anything vasoconstrictive (caffeine/chocolate)
3. no smoking
4. no compressive bandages until vascular status is stable
5. prevent compression from orthosis material and straps
6. constantly monitor color of the fingers with regards to capillary refill
7. no cold treatments in acute phase
8. do not use a whirlpool because it puts hand in dependent position
9. do not use contrast baths
10. mild heat may be used once vascularity has stabilized, but insensate hand does not have warning system for heat and cannot dissipate heat as well
11. no extreme elevation (above level of heart)

Question 13

dusky (grayish) finger/hand

Answer 13

indicates severely diminished vascularity caused by arterial compromise

Question 14

purple colored finger/hand

Answer 14

indicates severely diminished vascularity caused by venous congestion

Question 15

exercise and revascularization

Answer 15

should be performed in a warm room away from AC vents with the dressing off so the OT can monitor color, capillary refill, and temperature

Question 16

nerve injury clinical reasoning (3)

Answer 16

1. important to educate client in care of hand
2. after regained protective sensation, begin sensory reeducation
3. be aware that not only do that have problems sensing temperature, but they also have problems dissipating heat as well

Question 17

positioning for replant or if both flexors and extensors are lacerated

Answer 17

position similar to one for flexor tendon injury

*priority is given to flexors over extensors because flexion is more important for function

Question 18

edema

Answer 18

• causes increased resistance with AROM
• longstanding edema increases scar formation
• compression may be used after vascular system stabilizes

Question 19

delayed mobilization protocol (DMP) for replants

Answer 19

used mostly for young children or clients who may not be fully cooperative

Question 20

DMP 0-3 weeks

Answer 20

no ROM

Question 21

DMP 3 weeks

Answer 21

AROM of involved structures

PROM of uninvolved structures

Question 22

DMP 4 weeks

Answer 22

NMES

neuromuscular e-stim

Question 23

DMP 6 weeks

Answer 23

dynamic orthosis
PROM of involved structures
initiate use of hand for ADLs

Question 24

DMP 8-10 weeks

Answer 24

strengthening exercises

Question 25

early mobilization protocol for replants (EPM)

Answer 25

used for digital or hand replants characterized by stable fixation and a clean injury

Question 26

EPM 4-10 days

Answer 26

* EPM I * MP extension with wrist flexion * MP flexion with wrist extension

Question 27

EPM 7-14 days

Answer 27

* EPM II passive * continue EPM I * passively move client's fingers between "table" * MP flexion with IP extension (intrinsic plus) and hook * MP extension and IP flexion (

Question 28

EPM 14-21 days

Answer 28

* EPM II active * continue EPM I and EPM II passive * Place and hold hook and table positions * progress to active hook and table * isolated FDS tendon exercises * interossei strengthening (intrinsic plus) * light functional activities

Question 29

EPM 28 days

Answer 29

* increase wrist extension to full with flexed fingers * progress to full AROM and finger PROM * begin gentle blocking exercises

Question 30

EPM 6 weeks

Answer 30

* NMES * passive stretching of involved structures * full nonresistive use for ADLs (precautions for insensate hand) * dynamic orthosis use

Question 31

EPM 8 weeks

Answer 31

*light strengthening exercises

Question 32

tendon repair precautions (3)

Answer 32

1. protect against a full active fist or full extension of the fingers 2. avoid resistance from excessive co-contraction in early stages 3. edema increases resistance during early ROM exercise so modify your approach if you encounter resistance

Question 33

fracture precautions (2)

Answer 33

1. avoid excess stress at fracture, fusion, or pin sites when mobilizing a complex injury 2. if revascularization has been done in conjunction with fracture fixation, expect delayed healing or nonunion as a result of a decrease in the delivery of nutrients to the area

Question 34

nerve injury and repair precautions (4)

Answer 34

1. nerve injuries leave part of the hand insensate, so teach client to use caution with ADLs 2. use caution with use of dynamic or static progressive orthoses and any other external compression because of the lack of a warning system for ischemia 3. use heat and ice treatments cautiously 4. remind the client that cold intolerance and pain after nerve injury is common for 2+ years

Question 35

incision, wound, and graft precautions (3)

Answer 35

1. make sure that dressings do not exert shear or mechanical stress on healing wounds 2. prevent maceration while maintaining a moist wound bed 3. avoid using cytotoxic chemicals on granulating wound tissue